The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor(ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kid...The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor(ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lowerallograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor(CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.展开更多
Liver transplantation(LT)for colorectal liver metastases(CRLM)seems to be nowadays an established treatment,not only of unresectable CRLM(uCRLM)(1)but also for borderline resectable ones(2,3).For these patients,the be...Liver transplantation(LT)for colorectal liver metastases(CRLM)seems to be nowadays an established treatment,not only of unresectable CRLM(uCRLM)(1)but also for borderline resectable ones(2,3).For these patients,the benefit of LT vs standard modern advanced palliative therapies ranges between 40-80%(1).Notwithstanding the high rates of recurrence,LT can definitely be considered as a curative option,in particular considering the excellent long-term results recently published by the Oslo group(4).展开更多
Milan criteria are currently the benchmark related to liver transplantation(LT) for hepatocellular carcinoma. However, several groups have proposed different expanded criteria with acceptable results. In this article,...Milan criteria are currently the benchmark related to liver transplantation(LT) for hepatocellular carcinoma. However, several groups have proposed different expanded criteria with acceptable results. In this article, we review the current status of LT beyond the Milan criteria in three different scenarios-expanded criteria with cadaveric LT, downstaging to Milan criteria before LT, and expansion in the context of adult living donor LT. The review focuses on three main questions: what would the impact of the expansion beyond Milan criteria be on the patients on the waiting list; whether the dichotomous criteria(yes/no) currently used are appropriate for LT or continuous survival estimations, such as the one of "Metroticket" and whether it should enter into the clinical practice; and, whether the use of living donor LT in the context of expansion beyond Milan criteria is justified.展开更多
Background： lmmunosuppressive agents are still inefficient in preventing biopsy-proven acute rejection （BPAR） alter expanded criteria donor （ECD） kidney transplantation. The aim of this study was to investigate t...Background： lmmunosuppressive agents are still inefficient in preventing biopsy-proven acute rejection （BPAR） alter expanded criteria donor （ECD） kidney transplantation. The aim of this study was to investigate the relationships between early imrnunosuppressive exposure and the development of BPAR. Methods： We performed a retrospective study of 58 recipients of ECD kidney transplantation treated with enteric-coated-mycophenolate sodium, tacrolirnus （Tac）, and prednisone. The levels of mycophenolic acid-area under the curve （MPA-AUC）0-12h and Tac C0 were measured at the 1st week and the 1st month posttransplant, respectively. The correlation was assessed by multivariate logistic regression. Results： The occurrence rates of BPAR and antibody-mediated rejection were 24.1% and 10.3%, respectively. A low level of MPA-AUC0-12h at the 1st week posttransplant was found in BPAR recipients （38.42 ± 8.37 vs. 50.64 ± 13.22, P 〈 0.01）. In addition, the incidence of BPAR was significantly high （P 〈 0.05） when the MPA-AUC0-12h level was 〈30 mg·h-1·L-1 at the 1st week （ 15.0% vs. 44.4%） or the Tac C0 was 〈4 ng/ml at the 1 st month posttransplant （33.3% vs. 21.6%）. Multivariable logistic regression analysis showed that the MPA-AUC 0-12 h at the 1st week （OR： 0.842, 95% CI： 0.784-0.903） and the Tac C0 at the 1st month （OR： 0.904, 95% C7： 0.822-0.986） had significant inverse correlation with BPA R （ P 〈 0.05 ）. Conclusions： Low-level exposure of MPA and Tac C0 in the early weeks posttransplant reflects an increased acute rejection risk, which suggested that MPA-AUC0-12h 〈30 mg·h-1·L -1 and Tac C0 〈4 ng/ml should be avoided in the first few weeks alter transplantation.展开更多
Background:Hypernatremic donors was regarded as the expanded criteria donors in liver transplantation.The study was to investigate the effects of donor hypernatremia on the outcomes of liver transplantation and identi...Background:Hypernatremic donors was regarded as the expanded criteria donors in liver transplantation.The study was to investigate the effects of donor hypernatremia on the outcomes of liver transplantation and identify the prognostic factors possibly contributing to the poor outcomes.Methods:Donor serum sodium levels before procurement were categorized as normal sodium(<155 mmol/L),moderate high sodium(155–170 mmol/L),and severe high sodium(≥170 mmol/L).Furthermore,we subdivided the 142 hypernatremic donors(≥155 mmol/L)into two subgroups:subgroup A,the exposure time of liver grafts from hypernatremia to reperfusion was<36 h;and subgroup B,the exposure time was≥36 h.The outcomes included initial graft function,survival rates of grafts and recipients,graft loss and early events within the first year following liver transplantation.Results:There were no significant differences in the 1-year survival rates of grafts and recipients,1-year graft loss rates and early events among the normal,moderate high and severe high sodium groups.However,the overall survival rates of grafts and recipients in subgroup A were significantly higher than those in subgroup B.Cox model showed that the exposure time(HR=1.117;95%CI:1.053–1.186;P<0.001),cold ischemia time(HR=1.015;95%CI:1.006–1.024;P=0.001)and MELD(HR=1.061;95%CI:1.003–1.121;P=0.037)were the important prognostic factors contributing to the poor outcomes of recipients with hypernatremic donors.Conclusions:The level of donor sodium immediately before organ procurement does not have negative effects on the early outcomes following adult liver transplantation.For hypernatremia liver donors,minimization of the exposure time from hypernatremia to reperfusion is critical to prevent graft loss.展开更多
文摘The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor(ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lowerallograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor(CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
文摘Liver transplantation(LT)for colorectal liver metastases(CRLM)seems to be nowadays an established treatment,not only of unresectable CRLM(uCRLM)(1)but also for borderline resectable ones(2,3).For these patients,the benefit of LT vs standard modern advanced palliative therapies ranges between 40-80%(1).Notwithstanding the high rates of recurrence,LT can definitely be considered as a curative option,in particular considering the excellent long-term results recently published by the Oslo group(4).
基金Supported by the Association Llavaneres contra el Cáncer,No.IP004500
文摘Milan criteria are currently the benchmark related to liver transplantation(LT) for hepatocellular carcinoma. However, several groups have proposed different expanded criteria with acceptable results. In this article, we review the current status of LT beyond the Milan criteria in three different scenarios-expanded criteria with cadaveric LT, downstaging to Milan criteria before LT, and expansion in the context of adult living donor LT. The review focuses on three main questions: what would the impact of the expansion beyond Milan criteria be on the patients on the waiting list; whether the dichotomous criteria(yes/no) currently used are appropriate for LT or continuous survival estimations, such as the one of "Metroticket" and whether it should enter into the clinical practice; and, whether the use of living donor LT in the context of expansion beyond Milan criteria is justified.
基金This work was supported by grants from the major clinical research projects of the First Affiliated Hospital of Xi＇an Jiaotong University （No. XJTU 1AF-CRF-2015-005） and the National Natural Science Foundation of China （No. 81670681）.
文摘Background： lmmunosuppressive agents are still inefficient in preventing biopsy-proven acute rejection （BPAR） alter expanded criteria donor （ECD） kidney transplantation. The aim of this study was to investigate the relationships between early imrnunosuppressive exposure and the development of BPAR. Methods： We performed a retrospective study of 58 recipients of ECD kidney transplantation treated with enteric-coated-mycophenolate sodium, tacrolirnus （Tac）, and prednisone. The levels of mycophenolic acid-area under the curve （MPA-AUC）0-12h and Tac C0 were measured at the 1st week and the 1st month posttransplant, respectively. The correlation was assessed by multivariate logistic regression. Results： The occurrence rates of BPAR and antibody-mediated rejection were 24.1% and 10.3%, respectively. A low level of MPA-AUC0-12h at the 1st week posttransplant was found in BPAR recipients （38.42 ± 8.37 vs. 50.64 ± 13.22, P 〈 0.01）. In addition, the incidence of BPAR was significantly high （P 〈 0.05） when the MPA-AUC0-12h level was 〈30 mg·h-1·L-1 at the 1st week （ 15.0% vs. 44.4%） or the Tac C0 was 〈4 ng/ml at the 1 st month posttransplant （33.3% vs. 21.6%）. Multivariable logistic regression analysis showed that the MPA-AUC 0-12 h at the 1st week （OR： 0.842, 95% CI： 0.784-0.903） and the Tac C0 at the 1st month （OR： 0.904, 95% C7： 0.822-0.986） had significant inverse correlation with BPA R （ P 〈 0.05 ）. Conclusions： Low-level exposure of MPA and Tac C0 in the early weeks posttransplant reflects an increased acute rejection risk, which suggested that MPA-AUC0-12h 〈30 mg·h-1·L -1 and Tac C0 〈4 ng/ml should be avoided in the first few weeks alter transplantation.
基金the Ethical Committee of the Second Xiangya Hospital of Central South University(No.2019–050).
文摘Background:Hypernatremic donors was regarded as the expanded criteria donors in liver transplantation.The study was to investigate the effects of donor hypernatremia on the outcomes of liver transplantation and identify the prognostic factors possibly contributing to the poor outcomes.Methods:Donor serum sodium levels before procurement were categorized as normal sodium(<155 mmol/L),moderate high sodium(155–170 mmol/L),and severe high sodium(≥170 mmol/L).Furthermore,we subdivided the 142 hypernatremic donors(≥155 mmol/L)into two subgroups:subgroup A,the exposure time of liver grafts from hypernatremia to reperfusion was<36 h;and subgroup B,the exposure time was≥36 h.The outcomes included initial graft function,survival rates of grafts and recipients,graft loss and early events within the first year following liver transplantation.Results:There were no significant differences in the 1-year survival rates of grafts and recipients,1-year graft loss rates and early events among the normal,moderate high and severe high sodium groups.However,the overall survival rates of grafts and recipients in subgroup A were significantly higher than those in subgroup B.Cox model showed that the exposure time(HR=1.117;95%CI:1.053–1.186;P<0.001),cold ischemia time(HR=1.015;95%CI:1.006–1.024;P=0.001)and MELD(HR=1.061;95%CI:1.003–1.121;P=0.037)were the important prognostic factors contributing to the poor outcomes of recipients with hypernatremic donors.Conclusions:The level of donor sodium immediately before organ procurement does not have negative effects on the early outcomes following adult liver transplantation.For hypernatremia liver donors,minimization of the exposure time from hypernatremia to reperfusion is critical to prevent graft loss.
